Provider Demographics
NPI:1891763835
Name:FRY, CHARLEN (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLEN
Middle Name:
Last Name:FRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2309
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42702-2309
Mailing Address - Country:US
Mailing Address - Phone:270-706-1131
Mailing Address - Fax:270-706-1167
Practice Address - Street 1:200 BRULE ST BLDG 871
Practice Address - Street 2:
Practice Address - City:FORT KNOX
Practice Address - State:KY
Practice Address - Zip Code:40121-6100
Practice Address - Country:US
Practice Address - Phone:502-626-9745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38012207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP00081750OtherRAILROAD MCR
KY64067952Medicaid
KY000000300289OtherBC/BS PIN
KY2443136000OtherPASSPORT ADVANTAGE
KY50001558OtherPASSPORT
KYH86728Medicare UPIN
KY0668704Medicare ID - Type Unspecified